VNSNY CHOICE FIDA Complete Grievance and Appeals

 
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan) takes your care seriously. We strive to provide quality services and coverage to ensure that our providers and our staff treat you with courtesy and respect.  
 
As a participant in VNSNY CHOICE FIDA Complete, you have rights that protect your privacy, to receive covered services in a timely manner, and to be informed of and participate in decisions about your healthcare. These are explained in detail in your Participant Handbook (also called the Evidence of Coverage). Please see your Participant Handbook/Evidence of Coverage.
 
You have the right to make a complaint (or “grievance”) and an appeal. You can also appoint another individual to act as your representative to file an appeal on your behalf.  You may file your request with us verbally or in writing. 

Appointing a Representative
What is a Grievance?
How do I file a Grievance?
How do I file an External Grievance?
Time Frame for Filing a Grievance
What is an Appeal?
Types of Appeals: Standard and Expedited
Levels of Appeals
Time Frames for Filing Appeals
How do I file an Appeal?
How do I file Part D and Non-Medicare Prescription Part D Appeals?
Time Frames for Filing Part D and Non-Medicare Prescription Part D Appeals
Filing a Part D Exception
How Can Participants Obtain the Total Number of Grievances, Appeals, and Exceptions Filed with the Plan? 
Medicare Complaint Form
 

Appointing a Representative

To appoint a representative to act on your behalf, please use the Appointment of Representative form (CMS-1696) in English or en Español.

You must also complete an Authorization of Health Information form, in order for VNSNY CHOICE FIDA Complete to share confidential information about you and your health records. 

The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by VNSNY CHOICE FIDA Complete. ICAN may be reached toll-free at 1-844-614-8800 or online at www.icannys.org.

What is a Grievance?

A grievance is a type of complaint you can make if you are dissatisfied with the quality of care you receive from VNSNY CHOICE FIDA Complete or one of our providers. For example, you could file a grievance if:

  • You are treated rudely by anyone connected with your care.
  • You are unable to reach someone by phone or get the information you need.
  • You have trouble scheduling appointments in a timely manner.
  • You have a problem with your doctor’s office, whether it is the condition or cleanliness of the doctor's office, or you are kept too long in the waiting room.

How do I file a Grievance?

You can file a grievance in a few ways: orally via telephone, by fax or by mail.

You or an Authorized Representative, may file a grievance with
VNSNY CHOICE FIDA Complete or our providers by calling or writing to
VNSNY CHOICE FIDA Complete or our providers. 

By Toll-Free Telephone: 1-866-783-1444, 7 days a week, 8 am to 8 pm, (TTY: please call 711). Free Interpreter Services are available.

By Fax: 1-866-791-2213

By Mail:
VNSNY CHOICE FIDA Complete
Grievance & Appeals Department
P.O. Box 445 
Elmsford, NY 10523

How do I file an External Grievance?

You or your Authorized Representative may also file an External Grievance with the Centers for Medicare and Medicaid Services (CMS) by:

Phone: 1-800-Medicare
Email Link: https://www.medicare.gov/MedicareComplaintForm/home.aspx

Time Frames for Filing Grievances

All grievances must be filed within 60 calendar days of the incident or whenever there is dissatisfaction. Expedited grievances must be filed within 60 calendars days of the date of the coverage decision and must include a physician certification of need.

VNSNY CHOICE FIDA Complete will send written acknowledgement of the grievance to you and/or representative within 15 business days of receipt. If a decision is reached before the written acknowledgement is sent, VNSNY CHOICE FIDA Complete will not send the written acknowledgement. 

VNSNY CHOICE FIDA Complete will respond to your grievance as fast as your condition requires, but no later than, for: 

 a) Expedited: Paper review – A decision and notification will be made within 24 hours in certain circumstances. For all other circumstances where a standard decision would significantly increase the risk to your health, a decision and notification will be made within 48 hours after we receive all necessary information and no more than 3 calendar days from the receipt of the grievance.

Certain circumstances requiring a response within twenty-four (24) hours are defined as:
  • The complaint involves VNSNY CHOICE FIDA Complete decision to invoke an extension relating to an organization determination.
  • The complaint involves VNSNY CHOICE FIDA Complete refusal to grant a participant’s request for an expedited organization determination.

b) Standard: Notification of a decision will be given within 30 calendar days of VNSNY CHOICE FIDA Complete receiving the written oral grievance.

c) VNSNY CHOICE FIDA Complete may extend the 30 calendar day time frame by up to 14 calendar days if you or a provider on your behalf (written or verbal) requests the extension or if VNSNY FIDA Complete justifies a need for additional information and documents how the delay is in the interest of the participant. When VNSNY CHOICE FIDA Complete extends the deadline, VNSNY CHOICE FIDA Complete will immediately notify you and/or your representative in writing of the reasons for the delay.

VNSNY CHOICE FIDA Complete will notify you and/or your representative of the decision by phone for expedited grievances and provide written notice of the decision within 3 business days of decision.

What is an Appeal?

An appeal is the type of complaint you make when you want us to reconsider or change a decision about your health care service. For example, you could file an appeal if: 

  • We refuse to cover or pay for a service you think we should cover.
  • We or one of our providers refuse to give you a service when you think you should be covered.
  • We or one of our plan providers reduces or cuts back on a service you have been receiving.
  • You think we are stopping your coverage for a service too soon.
  • You can file an appeal if you want to reconsider or change a decision we have made about the services or benefits we cover for you.

Types of Appeals: Standard and Expedited

What is the difference between a standard appeal and an expedited appeal? 

Standard Appeal: A standard appeal is one where we make a decision about whether we will cover your medical care within the time frame of 30 calendar days for service appeals or 30 days for claims appeals.

Expedited Appeal: Expedited appeals shall be granted where a standard decision would significantly increase the risk to a Participant’s health. 

You can ask for an expedited appeal only if you or your doctor believe that waiting for a standard appeal could seriously harm your health or your ability to function. (Expedited appeals apply only to requests for medical care. You cannot get an expedited appeal on requests for payment for care you have already received.)

Levels of Appeals

There are four (4) levels of appeals:

  1. Initial Appeal to VNSNY CHOICE FIDA Complete
  2. Appeal to the FIDA Administrative Hearing Unit at the Office for Temporary Disability Assistance (OTDA)
  3. Appeal to the Medicare Appeals Council
  4. Appeal to the Federal District Court

Time Frames for Filing Appeals

  • You, your providers, and your representatives have 60 calendar days to file an appeal related to denial or reduction or termination of authorized Medicare or Medicaid benefit coverage. If there is a request to continue benefits while the appeal decision is pending and the appeal involves the termination or modification of a previously authorized service, the appeal must be requested within 10 calendar days of the notice's postmark date or by the intended effective date of the Action, whichever is later.
  • VNSNY CHOICE FIDA Complete will send a written acknowledgement of appeal to you within 15 calendar days of receipt. If a decision is reached before the written acknowledgement is sent, VNSNY CHOICE FIDA Complete will not send the written acknowledgment. 

VNSNY CHOICE FIDA Complete will decide the appeal and notify you (and your provider, as appropriate) of our decision as fast as your condition requires, but no later than the following timelines. 

  • Standard: Responded to within 30 calendar days for service appeals and 30 days for claim appeals.
  • Expedited: Responded to within 72 hours.
  • Extension: An extension may be requested in writing or orally by you or a provider on your behalf. The extension reason will be well-documented, and when VNSNY CHOICE FIDA Complete requests an extension we notify you in writing of the reasons for delay and informs the participant of the right to file an expedited grievance if he or she disagrees with the decision to grant an extension.
  • VNSNY CHOICE FIDA Complete will make a reasonable effort to provide prompt oral notice to you for expedited appeals and will document those efforts. VNSNY CHOICE FIDA Complete will send written notice within 2 calendar days of providing oral notice of its decision for standard and expedited appeals.
  • VNSNY CHOICE Complete will provide continuing benefits for all prior-approved Medicare and Medicaid benefits that are terminated or modified, pending internal FIDA Plan appeals, integrated Administrative Hearings, and Medicare Appeals Council if the original appeal is requested to VNSNY CHOICE FIDA Complete within 10 calendar days of the notice's postmark date (of the decision that is being appealed) or by the intended effective date of the Action, whichever is later.

How do I file an Appeal?

You can file an appeal in a few ways: orally via telephone, by fax or by mail.

By Toll Free Telephone: 1-866-783-1444, 7 days a week, 8 am to 8 pm (TTY: please call 711). Free Interpreter Services are available.

By Fax: 1-866-791-2213

By Mail: 

VNSNY CHOICE FIDA Complete
Grievance & Appeals Department 
P.O. Box 445
Elmsford, NY 10523

How do I file Part D and Non-Medicare Part D Prescription Drug Appeals?

You can file an appeal in a few ways: orally via telephone or by mail.

You, or an Authorized Representative or a prescribing physician may file an appeal concerning drug coverage (Part D) with MedImpact, our pharmacy vendor:

By Toll-Free Telephone 1-888-672-7203, Monday through Friday, 24 hours a day, 7 days a week. For TTY, please call 711.

By Mail:

MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Court 
San Diego, CA 92131

Time Frames for Filing Part D and Non-Medicare Part D Prescription Drug Appeals

The time frame for filing Part D and non-Part D drug appeals are as follows:

Your coverage as a Participant of VNSNY CHOICE FIDA Complete includes many prescription drugs. Most of these drugs are “Part D drugs.” There are a few drugs that Medicare Part D does not cover but that Medicaid may cover.

  • You, your providers, and your representatives have 60 calendar days to file an appeal related to the denial, reduction or termination of authorized Medicare or Medicaid drug coverage.
  • VNSNY CHOICE FIDA Complete will send a written acknowledgement of the appeal to you within 15 calendar days of receipt. If a decision is reached before the written acknowledgement is sent, VNSNY CHOICE FIDA Complete will not send the written acknowledgement.

VNSNY CHOICE FIDA Complete will decide the appeal and notify you, or your representative (and your provider, as appropriate) of our decision as fast as your condition requires, but no later than the following timelines:

  • Within 72 hours for all expedited drug benefit appeals.
  • Non-Medicare Part D Prescription Drug Appeals: For standard appeals within 7 calendar days from the date of the receipt of the appeal on Medicaid prescription drug appeals and no later than 30 calendar days from the date of the receipt of your other type of appeal.
However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take additional time to make the decision, we will send you a letter that explains why we need more time.

FILING A PART D EXCEPTION

If a drug is not covered in the way you would like it to be covered, you can ask VNSNY CHOICE to make an "exception." An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.

When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

If you or your doctor believes you should take a prescription that is not on the VNSNY CHOICE formulary, you may file an appeal called an exception using the Request for Medicare Prescription Drug Coverage Determination form.

To file an oral exception request, please call Member Services at 1-866-783-1444. (TTY/TDD users, please call 711) Interpreter services are also available.

Representatives are available 7 days a week, 8:00 AM to 8:00 PM.

  • Medicare Part D Appeals: For standard appeals as expeditiously as the participant’s health requires, but no later than 7 calendar days from the date of the receipt of the appeal.
  • Covering a Part D drug for you that is not on our plan's List of Covered Drugs (Formulary).
  • Removing a restriction on the plan's coverage for a covered drug.
  • Changing coverage of a drug to a lower cost sharing tier.
     

How can Participants obtain the total number of Grievances, Appeals and Exceptions filed with the plan?

To obtain the total number of grievances, appeals and exceptions filed with the plan, please call us at 1-866-783-1444, 7 days a week, 8:00am-8:00pm (TTY/TDD users: 711) or reach us by mail at:

VNSNY CHOICE
Attn: Grievance & Appeals Department
PO Box 445
Elmsford, NY 10523

Medicare Complaint Form

Click here to submit feedback about your Medicare health plan directly to Medicare using an electronic complaint form.

This is a FIDA-related page; some of the links will take you to non-FIDA information or to a different website.

VNSNY CHOICE FIDA Complete is a managed care plan that contracts with both Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. 

You can get this information for free in other formats, such as Braille or audio CD. Call toll free: 1-866-783-1444, TTY: 711, 8 am – 8 pm, 7 days a week.

Last updated 10/1/2016